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HomeMy WebLinkAbout13051 (16) � �X�°r� ' _ t CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES i _� 21660 E.Copley Drive Suitc 190 � (909)860-3195 Fax(909)861-31 l7 PRESS � ��•*��� BUQ.DING PERMIT APPLICATION FIRMLY � JOBS�TE " ' APPLICATION PERMIT P/C Q ADDRESS ' �� � ��� � DATE NUMBER '� �.,J # � ISSUE f� '�,f_� �� / TYPE OCC APN pT TRACT DATE�.-l.%i�1"`.""'�CONST. GROUP p OWNE� �_C.I.�L,�r_ '' " ADDRESS ` 7 •�� ZONING SETBACKS g CITY ZIP__ TEL. FRONT _ _ RW ❑ _ APPLICANT TEL.__ REAR ❑___ SIDE/SIDE STREET RW 1=7_ � CONTRACTOR � _ SIDE f7.___.__ _ � ADDRESS pROPOSED USE a CITY 21P , TEL. - � o ARCWENG/ _ -' -- W DESIGNER NO.DWEL. NO. NO. d ADDRESS - UNITS STORIES BEDROOMS � CITY ZIP TEL --J uyi DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION ¢ OWNER-BUILD�R DECLARATION SFR/AD�/REM O p I HEflEBV AFFlPoA UNDEfl PENALiYOF PERJURY THAT I AM EXEMPT FROM THE COYTRACTORS LI- (�afeJB/C0fP01S [L CENSE�AWFqRTHEFOLLAWINGREASON(SEG7037.SBt1SINESSANOPROFE5510NSC00[:ANYCITVOp (� U COUNi`(WHICHflEWIRESAPEflMfTTOCONSTflUCT,ALTER,IMPRUVE,DEMOLISH,ORflEPAIHANVSTRUG W p3ti0/DBCk Z 7IIHE,PHIOH TO ITS ISSUMICE,RL50 HEOl11RES THE APPLICANT FOF SIJCH PERMIT TO FILE A SIGN[� w 8TATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PHOVISIONS OF THE CONTRAC70P5 LI� � � CENSE LAW(CHAPTER o(COMMENCINO WITH SECTION'l000)OF DIVISION 9 OF THE BUSINE55 AYD PFO� � PDDUSpe FE33pN9CODE)ORYNAiHEORSHEISEXEMPTTNEREFflOMANDTHEBASISFORTHEALLEGEUEXEMP• (� TION.ANVVIOI.ATIONOFSECTION7o31.58YANYAPPLICANTFOHAPERM175U&IECTS7HEAPPLICANTTO Z R�Roof � AqVILPENRLNOFNOTMOHETHANFIVEHUNDRED�OLUR9(SSao).): - L71.ASOMMEROFTHEPROPERTV,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATIDN, 0 (;OfllmBfCldl - �� WILL DO THE WORK,AND TF7E STRUCTURE IS NOT INTENDEU OR OFFERED FDR SAL[(SEC.7040.BU51� J _ NESS ANO OROFESSIOYS CODE:TNE CANTHACTOPS LICENSE LAW OOES NOT APPLY TO pN OWN[R OF � PFqPERTYNR108Ui1D50HIMPROVESTMEREON,ANDWHODOE55l1Gh1WOqKHIMSELFORHERSELFOH � �. THqOUGHHISO{iHEROWNEMPLOYEES,PNOVIDEDTHATSUCHIMPROVEMEN7SARENOTIN7EN0EDOR m Q_ .OfFEAEDFOflSPLE.IF,HOWEYERTME8UIL01NGORIMPROVEMENiISSOLDWIYHINCNEYEAFOFCOMPIE� � __ Z 'TION,iHE OWNER-BUILDER WILL NAVE THE BURDEN OF PROVING THRT HE OR SH[OID NOT BUIL�OR . � IMPROYEFOflTNEPURPOSEOFS/LLE). �y� ❑I,/SOWNEROFTHEPflOPEqTV,AMEXCLU5IVELYCANiMCTINCWi7HLICENSEDCONTiiRCTOHS Q TO CONSTRUCT 7ME PROJECT(SEC.70�<,BUSINESS AND PROFESSIONS CADE:THE COYTRAG7oR5 LI� Vall18ti011 ____.___..__ .....__._NDJ.AREA,.___.,_ W CENSEIIIWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSOR!MPROVESTf{EREON,AND - � WriOCONTMCTSiOqSUCHPROJECTSWI7HRCONiFlRCTOR(S)LICENSEDPUHSUPMTOTHECONTRAG QUANTITY DE.ciCRIPTION FEE � 70RS IICENSE UW.). _� � J 3> C]IAMEXEMPT�NOFASEC.____ ^.___.B.BP.C.fOATHISREASON '. Q U �; ¢ DA7E ONRJER__' .__'.___ U Z W � LICENSED CONTRACTORS DECLARATION W �� I HEREBYAFFIRM UNOER PENALN OF PERJURY THA7 1 AM LICEMSED UNDER PROVISIONS OF CHAPTER � � � p�� B(COMMENCIM(i Wlhl SECTION 7000)OF DNISION 3 OF 7HE BUSINESS AN�PPOFESSIGNS CO�E,ANU � ��' � , YC� MYLICENSE IS IN ' FORCEAND EFFECT. � �u (�^ � �,T/� � �... � IICENSE�SS `�� LIC.NO. � �� DATE CONTRACTOft_ __�_ ,�,___ a � WORKERS'CDMPENSATION DECLARATION Q - � U � I HEREBY M UN�ER iENALTV OF PERIIIRY ONE OF THE FO!LOWING DECLAMTIO4S: � Q � IHAVEAN�N"LLMAINTAINACEfl71fICATEOFCqNSENTTOSELF-0NSUREFOfl1YOHKERS' z [bMPENSATION,AS PROVIDE�BYSECTION 37n0OFYHE LABOR CODE.FOR THE PEN4ORMqNCE W OFTHE WORK FOfl WHICH THIS PERMIi IS ISSUE�. � 0 W _fHAVEANDWILLMAINTAINWORKERB'WMPENSATIONINSURANCE,ASREOUIqEDBVSECTION � Q37000FTHELABDRCODE,FORTNEPERiORMA'NCEOFTHEWORKFORWHICHTHISPEflMIT15 � ISSUm.MYWORKFA3'COMPENSA�T�ONIf URANCEC IEFM'OPOLICYNUMOERARE: �.. CONSTFUCTION ,_ _...-..._ ..__.�...-_"" ?� cneRi�w_ � PL4NREVtEW _.....— ------� ---.... ---._.... - �--'---... � Z POLICVNUMBER � '� ' � E QTRIC � __ _... ,�A. _.._-._...__._ ...—.. __.. Q _'-' f :. 0.. (fFl53ECfX]NNE�NOTBEC��LElE00FTHEPEf0.ttI5FORONEHUNJ1iEUD0UAf4S(3100)ORLE554 PLUMBING . - '-_-.... .__..�� .�i�.. � ------ --` ;... Z I CERTIFV TXAT IN THE PERFOR4fANCE OF THE WORK FOR WHICH THIS PE.RMIT IS ISSl1EO,I � ME ANICAL -�-•��' ��-�� _"—"�,�"_-". .._ ....'_'__....— ������ (J-� SHALLNOTEMPIOYNVYPERSIXJINANYMANNER30ASTOBECOMESU3JECTTOTHE "" y WOflNERS'COMPENSATqNLAWSOFCALIFORNIA,ANUAOREETHATIFISHOULDOECAME I .E�TIONFEE ,_..._.._..._ �- — _. = SUBJECTTOTHEWJRKERS'COMPENSATIONPROVISIOIJSOFSECTION370oOF7HEUBOfl �SSUANCE � '��.y� _ CO�E,I SHAiL'L FORTHWITH COMPLY WIT OSE PqOVISI(1N --�---�--- � � --� ����---__. . p �ATE:�-�Y� . APPLICANT: �_. S�1T�J, -�`_�-�- -� ^ ---- J ��'-- ENERGY P/C ., �sr. .,p?t"��� ..._. .y WARNINO:FAILLIRETOSECUFEWORKERS'GOMPLNSAiIONGOVERFGEISUN NL,AND511ALLOE yy � x-{. �' -'-" J SU0.IECTANEMPLOYERTOCRIMINALPENAL7IESANDCIVILFINESUPTOONEIIUNDREOTHOUSMID F'�l!' ��,R��''� ..'F,�� '• F _ __""'_ �i _ ENERGY PERMI7 3. �+ i�,�� �� � OOLURS(f100,000),INADOITIONTOTHECOSTOFCOMPENSATION,DAMAPESRSPROVIDEDFORIN �•�3y-��q� ��f��:='T---i'--^`�t��--� �-----�----��-- ¢ SECTION37080FTHELABOFCODE,INTEREST,ANDATTORNE�'SFEES. {jETENTION FEE: �gy e�����'�, ._, ,_„_,_,___,�._ �c7.LlLP.'—',.—'.-. � CONSTRUGTION LENOING AGENCY ppE•ALT FEE: _....—._..,__ _....—.__._ .__ O —.._ �' I HEREBYAFFIRM UNUEP pENALTV OF PERJl1RV THAT THElIE�S A CONSTRUCTION LENOING AG[NCY __ ___ _____ _Y __ FOR THE PERf-0RMMICE OF THE WORK FOR WHICH THIS PEPMIT IS ISSUEO(SEC.3097,CIV.C.). W ---- --��:�,��.�- �Z LEN�ER'SNAME_ —""" __'...._ ' _ "__ ' _--- .._ .._ F- LENDEH'SADDRESS _.. wICERTIFYTHATIHAVEREADTI715APPUCATIONANDSTATETHATiHEABOVEINFOHMATIONISCORflECT. TOTAL FEES � IAGREE7000MPLVWITHALLG7VAN�CAl1NTYOH01NANf,ESANUSTATElAWSRELATINGTOBUILDING CIXJSTRUCTION,AND HEREBY AU fMORILE HEPRESEIVTATIVES OF THIS COU4TYT0 ENTEA UPON Tf 1E � � A[30VE-MENTIONE�PROPERT'FOR�NSPEC710NPUFPOSES. COMMEN7S _ _, .__ � �-��.�� � _ ���-- _,_.- - - ---- Q � IiTEE NAM[(PRIYT) _' '_' _—'._.. N �� �__ '—"' 'yy— — y SI ATU(iEOFPERMITfE � OATE 2 RECPL N0. .`�f� PAID BY �-' _VALIDATION___.,.___,_.,_._ - ~ WHI7E-0epaAment Copy,VELLOW-Finence Copy,PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy . . ... .. . ___ _ _._ k_ • � . � � : , { , _ , '' ..,,_. 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